The Internet Internist

Last September 6, a desperate Debbie Knight mailed a letter to medical authorities in Arizona.

"I write this letter to you today because I need your help," the Marysville, California, woman wrote the Arizona Board of Medical Examiners (BOMEX).

"There is a doctor living in Maryland who practices medicine over the Internet and telephone. His name is Pietr Hitzig [and], according to his own information, is the 'father of the fen/phen protocol,' which he believes to be cure for practically every condition known to man . . . I came to know this man as a result of a visit from my brother [Alvin Chernov], who lives in Arizona . . ."

Knight wrote to BOMEX a month after her 25-year-old sibling abruptly ended his troubling visit to her home. She described how he'd rarely slept during his weeklong stay--sitting at a computer into the wee hours. Inexplicably, Chernov had bundled some of her belongings for disposal. He'd pried apart computer disks, rendering them useless. He'd expressed his unrequited love for popular singer Meredith Brooks, and vowed to win her over.

One day, Chernov had surprised Knight and her husband, Kasen, with an expensive new home computer. He assured them his employer--a Scottsdale computer software firm--would reimburse him out of gratitude for his hard work. Knight learned later that her brother had been fired weeks earlier.

Chernov told her in the spring of 1997 that he was taking the diet drug combination widely known as fen-phen. (The "fen" refers to the appetite depressant fenfluramine, the "phen" to phentermine. Both are amphetamines.

Though he was overweight, Chernov wasn't taking fen-phen to lose weight. He told his sister that his doctor had been treating him for stress-related depression.

Knight also saw pill bottles marked Carbidopa and Levodopa among her brother's belongings. Those drugs normally are used to treat Parkinson's disease, not depression. Prescribing drugs "off-label"--for disorders other than those for which the medication was approved--is commonplace. But the Physicians' Desk Reference warns against prescribing Carbidopa and Levodopa to some patients: ". . . All patients should be observed carefully for the development of depression with concomitant suicidal tendencies. Patients with past or current psychoses should be treated with caution."

Alvin Chernov should have worn that warning on a sandwich board. The 1996 Arizona State University graduate had a history of depression, and his behavior at his sister's home was ominous.

Knight wrote that she spoke with Hitzig again a week later.
"I asked Hitzig if he had seen Alvin in person. He said no, that he did not need to--he had given Alvin a very thorough psychological test via the mail. . . . I asked him what he thought Alvin's problem was when he stayed for that week [in California]. Dr. Hitzig said he was simply taking too much of the fen-phen, and was becoming manic. Dr. Hitzig then told me I, too, should be on his protocol because I had the sniffles and the meds would clear it right up."

Knight said the doctor directed her to his Internet Web site, then hung up.
On August 15, Tempe police had delivered Chernov to Maricopa Medical Center for a court-ordered psychiatric evaluation. He was released August 26, after promising to undergo outpatient therapy with ComCare, Maricopa County's mental-health agency.

"I am greatly concerned for the future of my brother," Knight's letter to BOMEX concluded. ". . . I implore you to please do whatever is within your power to stop this type of medical practice. Alvin may never be the same again, and only time will tell if he will survive the physical and mental challenges he now must face."

One week later, on the morning of September 13, Chernov drove to his father's Glendale home. Minutes after arriving, he took a handgun owned by his father, Gary, stepped into a bathroom and shot himself in the head. He died at St. Joseph's Hospital the next day.

On September 15, the federal Food and Drug Administration ordered the recall of fenfluramine and dexfenfluramine--most commonly sold as Pondimin and Redux, respectively. It happened after the Mayo Clinic linked the drugs to a noteworthy incidence of heart-valve disorders. The news forced the lucrative diet industry and its millions of patrons to regroup. (Phentermine--the other half of fen-phen--remains on the market.)

That day, Debbie Knight again wrote to BOMEX, this time about her lost battle to save her brother's life.

"In my first letter, I asked for your help in stopping Dr. Pietr Hitzig . . . I know there is nothing anyone can do to help my brother at this point, but for others like him, I ask you: Please do not let this happen again."

Pietr Hitzig's treatment of Alvin Chernov raises many disturbing questions. Among them: When does a doctor's conduct stray beyond the bounds of professional negligence into the realm of criminal behavior?

The Chernov case also sheds light on the dark side of cyberspace, and on a doctor who has dispensed a potent chemical stew to thousands of patients he never met--and insists he's done nothing wrong.

"Isn't that what we're supposed to be doing these days," Hitzig asks New Times, "using advanced technology so we can improve our care and availability? I can give better support from 2,500 miles away than the average Arizona psychiatrist can give from five inches."

Arizona, like most states, has no laws against treating patients over the Internet. The public and politicians have yet to grapple with the issue of regulation of medicine in cyberspace.

That gap allowed Hitzig to mass-market his program over the Internet. "We have successfully treated over 8,000 patients," he claims in one of his Web site's blurbs.

Drug Enforcement Administration agents raided Hitzig's home and offices in Maryland on September 30, seizing his computers, files and other documents. The raid came after an agent posing as an out-of-town businessman contacted the doctor over the Internet and quickly got prescriptions for fen-phen and other drugs.

But Hitzig has yet to be charged with any crimes.
"It's an ongoing investigation, so I can't talk about it," says Baltimore-based DEA agent Cathy Gallagher, who was present at the raid. "I will say this case concerns a new area of concern for us--the Internet. It's complex, time-consuming stuff."

The feds have deemed both phentermine and fenfluramine "controlled substances," and doctors must obtain a license from the DEA to legally prescribe them.

A DEA affidavit filed at a federal court in Baltimore said the agency is investigating whether Hitzig prescribed drugs "outside the ordinary course of accepted medical practice," a crime. Courts have interpreted that phrase variously. (See accompanying story.)

But Arizona medical officials say they hold no sway over Pietr Hitzig. "We can only apply our regulations to doctors licensed in this state," says Donna Nemer, BOMEX's acting deputy director. "We can't do anything to this guy if he's not licensed in Arizona. That would be up to Maryland."

BOMEX could have issued a cease-and-desist order to Hitzig through the Arizona Attorney General's Office. It didn't. In fact, Debbie Knight says she agreed not to file a complaint against Hitzig in Maryland after a BOMEX investigator discouraged her by insisting that the doctor's arrest was imminent.

It wasn't.
Hitzig's license to practice medicine remains intact, says Charles Cichon, chief investigator for Maryland's Board of Physician Quality Assurance, that state's equivalent of BOMEX. Cichon says regulations keep him from revealing even if his board is investigating Hitzig.

However, the DEA affidavit says its interest in Hitzig stems from the Maryland board's December 1996 referral, which indicated it had gotten "numerous complaints" against the doctor.

Hitzig calls himself a victim, says the FDA had no basis to remove fen-phen from the market and considers the DEA raid "a totally political hit by a bunch of goons. They came in to destroy me, to kill my business. I'm still surviving, but I've had to downscale. The fake fen-phen scare and the raid has taken a bite out of me. If they--the medical board or the cops--had a good charge against me, don't you think they would have shut me down?"

Hitzig says he was unaware of Alvin Chernov's death until told of it by New Times:

"He died? Oh, my gosh. I knew those doctors in Arizona did some crazy things to his head. What did he do, commit suicide? That doesn't surprise me in the least. It was totally unnecessary. He was a wonderful guy."

In the wake of the FDA recall, most stories about fen-phen concerned the alleged incidence of heart-valve damage. Recent reports in medical journals and other data, however, indicate that far more fen-phen users have complained about profound mood swings and depression than heart problems.

That jibes with a mid-1980s report in which Swedish doctors questioned the safety of fenfluramine after getting numerous complaints from patients about psychiatric problems. But most of those patients had histories of psychoses, and the Swedes couldn't establish an ironclad connection.

Cause-and-effect also is a dilemma in Alvin Chernov's case. Did fen-phen and the other drugs Hitzig prescribed push an already-troubled young man over the edge? Or was his demise inevitable, with or without fen-phen?

It's impossible to say with certainty why someone chooses suicide.
But mental-health experts and others express shock at how readily Pietr Hitzig tweaked the brains of virtual strangers through cyberspace.

"I don't prescribe anything to people who just call up and ask," says Dr. Deborah Brogan, a psychiatrist at ASU's Student Health Center. "After a thorough, in-person evaluation, I'll recommend a medication to start with, if any. I'm not clear why this doctor was prescribing meds at all, and I don't understand this combination to treat depression. I always advise anyone with a mood disorder to avoid fen-phen because it's mood-altering."

Hitzig counters, "Look. If you use my technique, you'll stop all psychoneuroses. So, why should the doctor have to worry what the psychoneurosis is? You just fix the people. You tell them, 'Go down this list. If you got a stuffy nose, you increase your dopamine. If you're feeling anxious or hostile, you increase your seratonin. And you call me anytime you want.' I believe in taking care of people. I believe in medical care."

Phoenix-based DEA agent Tom Babicke says Hitzig's protocol reminds him of a movie from the late 1960s:

"Remember Valley of the Dolls? Remember all those actresses in that up-and-down syndrome--on amphetamines to lose weight, then not being able to sleep at night so they take sleeping pills, downers? Up and down, up and down. That sounds like the, quote, balance this guy is talking about."

Chernov's last employer, Paul Coppinger, says his brief interaction with Hitzig convinced him that the doctor is dangerous.

"Pietr Hitzig is an accredited con man," says Coppinger, co-owner of APPS Software International. "I'll stand by what I told him last summer."

What Coppinger told Hitzig via e-mail last August 8 was this: "I am very disturbed by the fact that you have prescribed such a powerful drug to Alvin without any direct consultation whatsoever. Even the most shady practitioner will require a face-to-face visit before 'forking over the goods.'

". . . Your electronic hucksterism is threatening the safety of not only Alvin, but the lives and livelihood of myself, my family and my employees. Further, your quest for profit has needlessly involved the attention of numerous police, judicial and medical professionals who must deal with the consequences of your actions and pick up the pieces of Alvin's shattered psyche."

One evening in August 1996, participants in an Internet "chat group" were gabbing about Pietr Hitzig.

"I am seeing a lot of anger against him," someone wrote, "but I have failed to see any posts actually posted by him. Someone fill me in please!"

Hitzig himself responded to the inquiry from his e-mail address, fenphen "I am the most competent to answer that question considering the quality of the responses you received. For instance, 'He's a creepy quack doctor who you should avoid at all costs!'"

To the contrary, Hitzig said, he was an Ivy League-educated (Harvard and Columbia) doctor who had developed "protocols re addiction and treatment of Persian Gulf illness, fibromyalgia and chronic fatigue syndrome."

He called himself the "creator of the term Fen/Phen (March 1993) and owner of the patent office's service mark for same . . . Creator of the Hitzig Fen/Phen protocol that has successfully stopped bulimia, alcoholism, depression, cocaine addiction, anorexia nervosa, Gulf War Syndrome, asthma, Chronic Fatigue Immune deficiency, post-traumatic stress disorder . . . (Please note that those success rates cannot be equalled in any other office, and that those who dispense these medications without being part of the Hitzig Fen/Phen team are doing so at the risk of damage to the patient.) I hope that gives you a better idea of who I am and what I do."

In another message around that time, Hitzig added, "I get pleasure out of helping patients, establishing the validity of what I do, and, frankly, make money. There is no reason to believe that they should be in conflict . . . I am not trying to sell you beach fronts in Arizona or the Brooklyn Bridge."

Not everyone on the Internet bought the doctor's pitch.
"He is the fen/phen guru and will explain to you how it's good for everything from depression to the gout," someone wrote. ". . . [Hitzig] doesn't let a little thing like a 100 percent financial stake in the protocol stop him from offering unbiased opinions. Needless to say, proceed at your own risk."

As he did with Debbie Knight, Hitzig referred chat groups to his Web site. There, he said, they could find all they needed to know about fen-phen, including the effectiveness of his program on "depression:"

". . . Resolution of depression usually occurs in 60 to 90 minutes. In a study of severely depressed alcoholics, 16 of 19 had normal psychological tests after two weeks of Fen/Phen treatment."

An internist by training, the doctor told the chat room he'd practiced general medicine for 20 years "before devoting himself to the exclusive treatment of patients" by prescribing fen/phen.

He said his regimen was "an exciting new treatment for many illnesses comparable in its potential to heal with the claims of 'snake oil' cures of the past. That idea that one treatment could help everyone has been a part of our society for thousands of years. Fen/Phen is THE medical treatment able to help society, and back its claims with research and testing . . ."

In August 1997--a month before Alvin Chernov died--Hitzig's Web site page said the cost for the first six months of his fen-phen program "is only $1,154," including a $350 down payment.

"Since July of 1996, we have been able to monitor patients by phone," Hitzig noted, "allowing continued treatment of patients outside of the Washington, D.C., area. Although we greatly prefer to see everybody in the office when the program is started, we can make exceptions if there are strong reasons that you can't make it to the office."

Alvin Chernov was one of those "exceptions." From the time he started taking fen-phen treatments in March 1997 until he killed himself six months later, he and Hitzig communicated only by e-mail or phone.

"A doctor makes decisions by listening, looking, by assessing the total picture presented by a patient," says Dr. George Lundberg, editor of the Journal of the American Medical Association. "If you don't even know what the patient looks like, then you don't know if the patient is conjuring, lying, misrepresenting or anything else. The Internet strips away much of that ability to communicate."

One clue to the amount of fen-phen Alvin Chernov ingested comes from receipts his father found after the suicide. Gary Chernov says the receipts for fen-phen and the other drugs totaled more than $3,500--more than three times what Hitzig's Web site says it would cost for six months.

The drugs phentermine and fenfluramine long had been available through prescription: The FDA approved phentermine for short-term use with a low-calorie diet in 1959, and okayed fenfluramine as an appetite depressant in 1972. But neither drug had grabbed a foothold because, individually, they were only mildly effective. Like most drugs, they have side effects--among them, depression with fenfluramine and, in rare cases, psychotic episodes with phentermine.

In 1992, the nation's pharmacists filled only about 60,000 prescriptions for fenfluramine.

Then, in July 1992, a researcher issued findings that caused the popularity of what became known as fen-phen to soar. Dr. Michael Weintraub claimed the drugs, taken in tandem, melted away pounds while negating each other's side effects.

Weight-loss clinics based almost solely on fen-phen--including at least five in the Valley--popped up after Weintraub's findings were publicized. In 1996, druggists filled more than six million prescriptions for fen-phen.

Pietr Hitzig was one of the first to jump on the bandwagon. In late 1992, he coined the term fen-phen. And he was savvy enough in the early 1990s to recognize the burgeoning communication device called the Internet.

Alvin Chernov's life was difficult long before he heard of Pietr Hitzig, fen-phen or the Internet. He was the third of four children in the tumultuous Phoenix household of Gary and Martha Jean Chernov.

Severely asthmatic, Alvin spent most of his time as a child indoors, honing a bent for mathematics and science. His sister Debbie says Alvin never had many friends, but the few to whom he warmed knew an intelligent, serious and sensitive young man.

Gary Chernov scraped by in a variety of small business ventures, some of which made money. His wife ran the household, which Debbie Knight--now 27--describes as volatile.

In the early 1980s, Martha Jean Chernov disappeared for about a month. She later told Debbie Knight she'd planned to starve herself to death--haunted by what she said was sexual abuse by her own father as a child.

"I don't know how our mother was so good to us with all of her own problems and a lousy marriage, but she was," Knight says. "I didn't know until after Alvin died how much she really meant to him."

Chernov attended Phoenix Central High, an honor student who kept to himself and seemed destined for a career in computer science. He never had a girlfriend, either in high school or at college, though not because he didn't want one. He wasn't bad-looking, but his family members agree he lacked basic socialization skills.

Chernov enrolled at ASU after graduating from Central in 1990. He moved out of his parents' home and, according to sister Debbie, began to blossom.

"I was just so proud of him," she says. "He was working out and he looked great. He was even showing some dance moves. He wasn't just this little computer dork anymore."

In June 1992, Martha Jean Chernov again disappeared. Passersby found her skeleton in late 1993 at the base of a cliff in the Superstition Mountains. Pinal County authorities ruled the death an "accidental fall."

For reasons he kept to himself, Gary Chernov never told his children about his wife's death. Debbie Knight wouldn't learn of it until August 1994, when she called the Pinal County Sheriff's Office for an update on her mother's missing-person case.

To his family, Alvin seemed unfazed by news of his mother's death. He wasn't. After he killed himself, police scanned a disk in his computer for clues. Data on the disk included a journal--he called it his "book"--Alvin began in his last months. Titled How I Think, it starts with a dedication to Martha Jean:

"I never told you this, but you were my hero. I looked for guidance about everything. You were the only person I felt I could tell anything. When you died, a part of me died with you. There were many times I wondered how I would make it through life. I had not yet learned all you wanted me to learn. What was wrong with you? Why did you leave me before I had the strength to carry on with your work?"

After learning of his mother's death, records show, Chernov got a prescription for the anti-depressant drug Prozac from doctors at ASU. But anguish didn't dampen his academic achievements. Chernov graduated from ASU summa cum laude in May 1996, with a degree in engineering.

That summer, he went to work as a software engineer for Xantel, a Phoenix firm. Though the reasons are murky, he was fired in late 1996. Months later, after Xantel gave Chernov a poor referral, he mailed a former boss a photo of the bombed federal building in Oklahoma City.

Chernov apparently started taking fen-phen between jobs, in March 1997.
"Alvin told me that spring that he'd been taking this medication for depression," Debbie Knight recalls. "He said, 'It's all about chemistry,' that he was playing with the levels he was taking, that his head was better and he was losing weight, too. It sounded great, and I completely believed him. I had no idea it was through the Internet."

In April 1997, Paul Coppinger of APPS Software hired Alvin Chernov for his Scottsdale firm.

"You can't get out of ASU's engineering program with such a high grade-point average without knowing your stuff," says Coppinger, a thoughtful man in his mid-30s. "We identified that Alvin might be a bit eccentric, but some eccentricity can be fine in a programmer. Unfortunately, we soon found he wasn't getting his work done, and that he was really out on the fringes."

He says he counseled Chernov about his work habits.
"We wanted him to be a winner with us, so we gave him easy projects to develop a pattern of success. He felt I was abusing him. Finally, I called him in and said, 'Tell me what the barriers are--we'll work with you.' He e-mailed me afterward, and that was it."

Sent last June 19, Chernov's e-mail message said, "If you want me to continue beyond 12 p.m. today, you will provide me with a written offer that details my job description, how my performance is to be measured, exactly how I am to be paid based on such performance . . . No discussion. Take it or leave it."

Coppinger left it, firing Chernov that evening.
Chernov didn't tell relatives he'd been dismissed.
On July 2, Tempe police informed another of Chernov's sisters, Meredith, that they'd responded to a 911 call from his apartment. Reports show he told an operator someone was trying to break into his third-floor apartment.

Chernov left a message on Knight's answering machine that night: "Well, sis, I managed to piss off the CIA, FBI and Tempe Police Department, and they may off me."

He then e-mailed Paul Coppinger a spree of vaguely threatening missives.
"In recent years in America, there have been a number of horrible elephant attacks on elephant trainers," Chernov wrote. ". . . In India, elephant attacks are very rare despite very close training handling."

The message deeply disturbed Coppinger, but he didn't respond, to this or any of Chernov's subsequent e-mails. On July 26, Chernov wrote to his former boss, "Important warning: At this point, I do not know what to do other than warn too much good feeling is just as dangerous as too much bad feeling. Pride the fall, etc."

On July 30, another e-mail message chilled Coppinger: "I am not sure why I have difficulty eating and sleeping. As far as I know, I still feel fine. So far, I feel very, very calm. Even I know there is a time to kill. I just know right now is not the time for me to decide."

Coppinger had read enough. He obtained an order of harassment against Chernov from a local court. He had an alarm system installed at his home. He sent his pregnant wife and three young children out of state.

On July 31, Chernov drove to California in his Honda Accord to visit the Knights. The trip would be portentous.

The couple anxiously awaited Chernov's arrival.
"He said he needed to be with people who could look at him like he was normal," Debbie Knight says. "We were hoping everything was all right with him, but I wasn't sure."

Chernov seemed himself, if somewhat more scattered, on his first day in Marysville, the couple recall. They assumed at first that he was unwinding from his high-stress job at APPS Software. But they soon saw that Chernov was unable to hold a train of thought, except for a fixation on his would-be "girlfriend," music star Meredith Brooks.

He stayed up at night, explaining that he was working on a top-secret software program for the CIA.

One day, Chernov returned with a new computer as a gift for the couple. He told them that Paul Coppinger would reimburse him for it. Actually, Chernov had charged the $2,900 computer to his own credit card. The Knights later returned it.

Chernov's behavior grew odder, the Knights say. He sifted through their belongings, then bagged them for disposal. He also took apart computer disks and offered no explanation when Debbie Knight gently confronted him.

He sent several new messages to Paul Coppinger, including one that a mental-health worker later cited as evidence that Chernov was hearing voices and belonged in a psychiatric ward. One message said, "I seem to constantly be hearing the following words in my mind: 'Sunny came home with a list of names. It's time for a few small repairs,' she said.'"

The worker apparently didn't know that Chernov was reciting a lyric to Shawn Colvin's hit song.

Toward the end of his visit, Chernov announced he was going to Los Angeles to meet Meredith Brooks and apply for a job at her record label, Capitol. He grabbed a few Pepsis, his Brooks CDs and his ASU diploma--which he'd brought with him from Tempe--and drove away.

After Chernov left, his sister looked through his belongings for clues to his erratic behavior.

"We knew he was in serious trouble, and I wasn't sure what to do," Debbie Knight says. "I found his bottles for Carbidopa and Levodopa--he told me he was taking his fen-phen with him--and I called the pharmacy on the label, Marty's Discount Pharmacy of Mississippi [located near Jackson]. 'My brother's acting really crazy, and I have to know what's going on.' A woman tells me the doctor who prescribed the stuff, Hitzig, was excellent, cutting-edge."

Chernov returned the next day, the Knights say, collected a basket of his clothes and left again minutes later, saying little. He left a note that instructed the couple to call Paul Coppinger if they needed anything.

Debbie Knight introduced herself to Coppinger by phone on August 6. It was then she learned that Chernov had been fired weeks earlier. Coppinger also told her about the e-mails and the order of protection against her brother. In turn, Knight informed Coppinger that her brother seemed unstable.

Coppinger agreed to call Valley mental-health authorities, which he did on August 7. That jump-started the county's emergency commitment process.

The next day, Debbie Knight spoke to Pietr Hitzig for the first time. She documented the call in her journal, dated August 8, 1997, 6:51 p.m.:

"Called Hitzig at home. Said Alvin appears to be fine. Not suicidal at all, plans to write a book . . . Then spoke with Coppinger. Paul wondered about a doctor treating Alvin from Maryland. He thought that was rather strange. So do I, frankly."

Coppinger was doing more than wondering. He told Hitzig by e-mail last August 10: "People are harmed and die when doctors believe that their decisions are unimpeachable and their moral foundations secure. I believe that in matters of life and death you get no second chances, and I refuse to gamble with the safety of those I hold dear. Would you do otherwise?"

Hitzig replied that day, also by e-mail: "After reading your intemperate note, I can see why Alvin Chernov dislikes you so much . . . In fact, if Alvin called you any disparaging name he must be correct. Why don't you get under the rock you came from?"

On August 14, Debbie Knight again spoke to Hitzig, and told him she'd spoken to Coppinger. She noted his response in her journal: "'Oh, he's [Coppinger] insane and completely antagonistic. I can see why Alvin dislikes him.' He [Hitzig] did say he had received the e-mails [from Chernov to Coppinger] and he didn't think they were that bad."

Later that day, Chernov called his sister in a rage.
"I do not appreciate you calling my doctor!" he shouted into a message machine. "Leave my fucking doctor alone!"

After a brief investigation, ComCare officials on August 15 asked a Superior Court judge to order Chernov's psychiatric evaluation at Maricopa Medical Center.

The judge signed the order and, that night, Tempe police delivered Chernov to the hospital.

Alvin Chernov was not a willing participant in his mental evaluation and treatment. Records of his 11-day stay say he insisted that he was fine and needed to get on with his life.

He tested positive for amphetamines on the day he arrived, which doctors later attributed to fen-phen. Chernov told doctors he'd stopped taking the Carbidopa/Levodopa combination. But he said he'd been using fen-phen up to the day of his commitment.

On August 19, hospital records indicate, Chernov told a doctor that fen-phen "could have been a problem" for him. But he also expressed concern that no one from the hospital had contacted his doctor, Pietr Hitzig.

"Dr. Hitzig insists that Alvin does not belong here in the hospital. He admits, '[Alvin] got manic, and I told him to lower the medications.'"

Hitzig says he sent e-mail to his Arizona patients--about 25 at the time, he estimates--asking them to intervene:

"I asked them to do anything they could to help this kid who was being kept locked up unjustly. Alvin was totally balanced on my program--and the psychometric tests [a standarized questionnaire of 90 queries] proved it--until those doctors did those crazy things to him."

On August 22, Dr. Glenn Lippman, a psychiatrist at Maricopa Medical Center, spoke to Hitzig by phone in the presence of several associates.

"Dr. Hitzig insists that the patient needs fen-phen and other meds to 'modulate his seratonin/dopamine' which he was prescribing via Internet for patient's 'addiction and depression,'" Lippman's notes say. (Seratonin and dopamine are the brain chemicals altered by fen-phen.)

". . . Dr. Hitzig confirmed that he has never seen patient and evaluated via Internet and [psychological test] at last 'eval' in early August. And Hitzig stated that he never performed or recommended any physical exam, labs or vital signs because in his experience with over 7,000 patients it hasn't been needed. Dr. Hitzig stated patient had positive response to his medications . . . Dr. Hitzig ended conversation stating that he disagreed with our clinical approach to not continue fen-phen."

Social worker Margaret Lothian's written recollection of the call added another dimension: ". . . [Hitzig] said repeatedly that patient will become mentally ill if he's not on these meds."

But Alvin Chernov already was mentally ill.
"He continues to believe the CIA wants him to work for them," Brennan noted on August 22. "He continues to have the idea that Ms. Brooks would be receptive to his dating her."

Arizona laws mandate the placement of the mentally ill in "least restrictive" settings. That sometimes means the premature release of patients who may be left to fend for themselves--for better or worse.

Chernov's attorney, assistant public defender Mary Miller, requested a hearing to consider his release to "outpatient" status. On August 26, a court commissioner ruled that Chernov was "persistently or acutely disabled, is in need of treatment, and is either unwilling or unable to accept voluntary treatment." At the same time, however, commissioner Jane Bayham-Lesselyong ordered Chernov's immediate release, with one year of mandatory outpatient treatment with a ComCare psychiatrist.

"With a structured environment, supportive therapy and medications, the patient should become less enraged," Brennan wrote to the court before the hearing.

Chernov would be dead less than three weeks later.

Alvin Chernov's rage would not diminish after his release, as his psychiatrist had hoped.

His "environment" wasn't structured. His Tempe roommate asked him to move out by the end of September, and he didn't know where to go. At least in Chernov's mind, he was not receiving "supportive therapy" from his new ComCare psychiatrist, whom he despised.

That psychiatrist issued him drugs--Zoloft, an antidepressant, and Zyprexa, an antipsychotic--four days before the suicide. But postmortem blood tests didn't determine if he'd taken the antidepressants--or if he had resumed using fen-phen.

Even if Chernov had quit fen-phen, say two doctors and a pharmacologist contacted by New Times, the dramatic change in his seratonin and dopamine levels may have caused him to plummet into an even deeper funk. That may lend credence to Hitzig's argument that removing Chernov from fen-phen may have been dangerous.

Chernov's journal entries indicate his love affair with fen-phen wasn't over. In an undated entry, he explained: "The fen/phen protocol under Dr. Hitzig is [a] very good one. I know that many people will try to blame my wildness on fen/phen. My wildness was not due to fen/phen, but rather to the near-constant intrusions on my privacy. Fen/phen was the only treatment program that seemed to help."

Chernov wrote to Hitzig last August 28, two days after his release from the psych ward.

"I was ordered to stop fen-phen," his letter said. "I guess I'm glad to be free. I've decided to delay my book until I've recovered from the 'help' being given by Maricopa County. The county wants to 'help' me for a year. According to the true spirit of progress, my shrinks have ordered me to stop the fen-phen. So I am suspending my use of fen-phen for right now. . . . In about 60 days, I'll have the opportunity of having my case reviewed . . . Right now, I'm working on getting my debts in order and finding work as a computer tutor. I love programming; it's just the many, many dumb bosses that I dislike. Thanks for your help so far."

Chernov spent endless hours at his apartment in early September, preparing job applications and typing How I Think into his computer. In the latter, he listed four goals for the coming year: "Get and keep a job. Publish How I Think by Alvin Chernov. Get a different psychiatrist. Meet Meredith Brooks."

But Chernov's life was in tatters. He couldn't get a job. He had no friends to rely on, and he'd estranged himself from his siblings, often launching into diatribes when he spoke with Debbie Knight by phone.

"I fear what will happen if I do not get a job," he confided in his computer journal.

On September 7, Chernov sent a letter to Knight, defending Hitzig. "Dr. Hitzig is short with most people probably because he is tired of explaining the same thing to people because it is unconventional," it said. "I understand that shortness completely."

Knight soon phoned her brother's ComCare caseworker, Omar Clark, of whom Chernov had spoken highly. Clark's case notes say Knight told him Chernov was broke and had no place to move to, but that Gary Chernov wasn't going to let him move in.

On September 11, Alvin Chernov phoned his sister to apologize for his behavior.

"He said he wanted to call while the [antidepressant drug] Zoloft was in effect," she recalls. "He told me how tired he was--'Is it always going to be like this?' He was talking about giving up his car, which he loved. He says, 'Debbie, the darkness comes and the darkness goes.' It was the scariest thing."

Knight says she tried to call Omar Clark the next day, to no avail.
On September 13, Chernov stopped at his father's home about 10 a.m. Gary Chernov and his girlfriend were having a yard sale.

Alvin sat outside with his father for a few minutes, asking where he could buy a gun. Gary tells New Times he told Alvin he couldn't buy a gun because of his precarious mental state. Alvin insisted he needed a weapon because he'd been held up at gunpoint the previous night in Tempe. He stood up and walked into the house.

There was a loud bang. Gary's girlfriend rushed to the bathroom, and saw blood running out from under the door. Alvin was still breathing when help arrived, but he was effectively dead. Doctors kept him on life support for more than a day, during which time his family decided to allow his vital organs to be harvested for transplantation.

At Alvin's apartment after the suicide, Gary Chernov found bottles of fen-phen and the other drugs prescribed by Hitzig and the ComCare doctor.

"I don't blame Alvin for killing himself," he says. "I blame Hitzig. Alvin was totally, thoroughly screwed up in the head after he started taking those drugs."

The day after Alvin Chernov was pronounced dead, the FDA ordered the recall of fenfluramine and dexfenfluramine.

Media from around the globe called Pietr Hitzig--the self-proclaimed "father of fen-phen"--for comment. The doctor appeared on a national radio talk show, comparing the situation to the recall of meat by a packing plant after the discovery of tainted hamburgers.

"Nobody died," Hitzig said, referring to both fen-phen and the burgers.
Hitzig took the opportunity to pitch his new program, which he dubbed "Nibbles-McBride"--nibbles because patients nibble the drugs instead of swallowing them whole, McBride after one of his patients. The regimen, which is also called "PhenFour," includes phentermine and the Parkinson's drugs that Hitzig prescribed to Alvin Chernov. Fenfluramine is absent from the new concoction.

The affidavit that DEA filed in connection with its September 30 search of Hitzig's office described an undercover agent's dealings with the doctor, which mirrored what is known about Alvin Chernov's. Posing as a businessman from Texas, the agent contacted Hitzig by e-mail, saying he wanted to lose weight and stop smoking. Hitzig e-mailed him back, "We do have patient treatment by phone. No doctors there in Texas."

The agent sent a down payment of $350 to Hitzig's office. One of the doctor's employees gave him the name of an Annapolis, Maryland, pharmacy that would dispense the drugs. The agent sent the pharmacy a money order. Within days, he received a package of pills by mail. The parcel included fen-phen, Carbidopa and Levodopa, and sleep-inducing drugs. Soon after that, Hitzig explained his protocol in a 75-minute conference call with the undercover agent and three other new patients.

Though he's not facing criminal charges, Hitzig admits the DEA raid has devastated his business. He filed a Chapter 11 bankruptcy petition last November 20, listing $150,000 in assets and $242,000 in liabilities. The filing may shield his assets from any civil judgments against him, including a class-action lawsuit filed late last year by Baltimore-area patients who claimed they developed heart problems after taking fen-phen.

The doctor tells New Times that he never has grossed "more than about $900,000 or a million dollars" in one year, and hasn't netted more than about $220,000 in a year. He says his overhead costs--"A big office, lots of staff, et cetera,"--account for the relatively low level of listed assets and liabilities, adding: "I give a lot of freebies. I never turn down a drug addict, an alcoholic, anyone for that matter."

Other fen-phen lawsuits are focusing on the drugs' adverse mental aspects: An ex-Florida judge recently settled out of court for $250,000 against his prescribing physician--not Hitzig--after claiming he'd resigned because of psychiatric and other disorders allegedly caused by fen-phen.

But Pietr Hitzig is unrepentant.
"I've got lots of Alvin Chernovs who are still alive because of what I do," he says. "I've got some people who are psychotic. I've got people who are heroin-addicted leading totally normal lives . . . I can stop cocaine, heroin. Nicotine, I'm sure I can do, but I haven't spent enough time on it. You give me someone with a craving for [crystal methamphetamine], and probably within five minutes, I'll have the craving stopped.

"You have to regulate the dopamine and seratonin by one means or another. Meditation. Acupuncture does it somewhat. Even traditional medicine. Therapy. Prayer. There's many mansions in God's kingdom. My way just happens to be the most effective way."

Debbie Knight wrote a short eulogy for her brother. In it, she recalled their last conversation, two days before he killed himself, and Alvin's darkness-comes-and-the-darkness-goes epiphany.

"Now, my brother," she wrote, "you will never again remain in darkness. We will all miss you, we all love you. . . . Goodbye."